ISSUE BRIEF

NO. 15 National Quality Forum JUNE 2009

Waste Not, Want Not The Right Care for Every

Overuse: A Critical Component EXECUTIVE SUMMARY of Health Reform and a National Priority Up to 30 percent of healthcare services delivered each year in the Of all the barriers to national healthcare are estimated to be unnecessary. This overuse, amounting reform, one of the biggest is the question to approximately $700 billion a year, is both wasteful and often danger- of how to pay for it. Expenditures in the United States for healthcare surpassed ous to . The National Priorities Partnership has identified $2 trillion in 2006, almost three times the overuse as one of six priority areas that target reform in ways that will $714 billion spent in 1990,1 and yet in 2007, eliminate waste, harm, and disparities to create and expand world-class, 45 million Americans, or 17.8 percent of the U.S. population, lacked health patient-centered, affordable healthcare. Overuse—which has been insurance.2 Many observers legitimately defined as the situation that occurs when “the potential for harm wonder how the United States could exceeds the possible benefits of care”—happens in every setting possibly shoulder the financial burden of reform, considering that so much and sector of healthcare. Much of overuse stems from unexplained currently is spent on healthcare without variations in the amount, type, and intensity of medical care. Overuse providing full access to care. is a culture-driven problem, and, as with all culture-driven challenges, And yet, President Obama and Congress are determined to enact legisla- solutions exist, but they must be robust, and they take time to be tion for significant healthcare reform in successful. Potential solutions include implementing a “shared 2009. The President’s Fiscal Year 2010 decisionmaking” approach to healthcare that engages patients as fully budget blueprint contains a $634 billion fund designed to finance expansion of equal partners in their own care; implementing information technology health coverage for the uninsured and systems to ensure that medical decisions are informed by the best improve care over the coming decade. possible data; and reforming the healthcare payment system to enhance This is being termed a “down payment on healthcare reform that will bring incentives to provide the right care rather than the most care.* down costs and expand access.”3 One need not conclude that health- *On March 25-27, 2009, the National Quality Forum held a conference in Cleveland, Ohio care reform will necessarily lead to (called the Spring Implementation Conference), convening multiple speakers from across the higher costs over the long run. Evidence stakeholder spectrum to discuss overuse and consider potential solutions. Many of the quotes in this Issue Brief are taken from speakers’ speeches and presentations at that conference. demonstrates that up to 30 percent of

Ü Continued on page 2 healthcare services delivered each year in not getting the medical tests and treat- care.22 Healthcare stakeholders are now 9 the United States are unnecessary. This ments they need.” And, with economic turning their attention toward raising overuse, amounting to approximately $700 conditions remaining sour, more than public awareness of the dangers of over- billion a year, is both wasteful and often half of Americans report that they are use. Examples include the Partnership for 4 dangerous to patients. Many observers postponing or skipping treatments because Healthcare Excellence, a Massachusetts 10 from across the stakeholder spectrum of cost. effort that has run an advertising campaign agree that eradicating overuse would make Although underuse stemming from to inform consumers about variability in healthcare both safer and more efficient economic challenges and/or lack of access care,23 and AARP’s work to inform its and that the savings generated could be remains a critical issue, a growing body members about “overtreatment” in mem- applied toward financing a national of evidence indicates that a significant ber publications.24 But, there is still much healthcare reform effort, should they be portion of the care Americans receive is work to be done. “The national attitude marshaled in such a way that resources are redundant and unwarranted—and beyond toward overuse in healthcare has been redirected toward expanding insurance that, in some cases, even harmful. remarkably cavalier,” says Wendy Everett, 5 coverage or addressing underuse. Overuse has been identified as a ScD, president of the New England In 2008, the National Priorities problem in healthcare for at least two Healthcare Institute.25 But, the current 11,12,13 Partnership identified overuse as one of decades. It was defined more than economic crisis is reviving interest among six priority areas that target reform in 10 years ago as the situation that occurs employers and health plans to address ways that will eliminate waste, harm, and when “the potential for harm exceeds the waste now. “There is a financial and moral disparities to create and expand world- possible benefits of care.”14 Peter R. Orszag, imperative to eliminating overuse and class, patient-centered, affordable health- President Obama’s budget director, has waste,” says Jennifer Eames, associate 6 care. The National Priorities Partnership, refined the definition of overuse with an director of the Pacific Business Group on a diverse group of national organizations economics lens to “include cases in which Health.26 representing those who receive, pay for, the added costs of a more expensive service Although there is no unanimity on deliver, and evaluate healthcare, includes did not exceed the added benefits it was how to reduce overuse, it is broadly overuse on its action agenda to transform expected to provide.”15 More recently, recognized that the healthcare community healthcare during a time of severe economic researchers have determined that waste in must look from within to find ways to strain by better investing resources to the stems from three main reduce overuse. “The medical specialties fundamentally improve patient care and factors: practice variations, adverse events, need to take a hard look at their own outcomes. and overuse of the emergency department practices and determine what to target “There is far too much waste and (ED) for nonemergent conditions.16 and how to change the status quo,” says inappropriate care in healthcare provided Overuse, or waste, can take many Bernard M. Rosof, MD, MACP, chair of in the United States today,” says Janet forms, such as: the AMA-convened Physician Consortium Corrigan, PhD, MBA, president and CEO • Diagnostic imaging procedures that for Physician Improvement. Furthermore, 27 of the National Quality Forum, which con- are duplicative, faulty, unwarranted, there is urgency to the issue. “We have to vened the National Priorities Partnership. or lead to unnecessary procedures.17 think very hard about whether change is “Removing that waste would encourage happening fast enough,” says Gerald M. • Spine surgeries for back pain that appropriate use and enable us to achieve Shea, assistant to the president for govern- 7 often do not result in better outcomes effective, affordable care.” 18,19 mental affairs at the AFL-CIO. “We have for patients. to ask how much money are we saving. If • ED visits that could be avoided we don’t want the economists to answer The Challenge through expanded access to primary 20 the question for us, we’d better do it care. 28 Today, a significant amount of popular ourselves.” attention on healthcare focuses on the care • Rehospitalizations that could be The balance between underuse and that Americans do not receive. “Practically prevented with better coordination of overuse often is referred to as appropriate 21 everything in our personal interactions care. use. “Waste occurs when the right care with the system tells us that A sizeable number of Americans isn’t delivered to patients at the right far from getting too much care, we’re (about half) believe that the American time,” says David Nexon, senior executive getting too little,” writes author Shannon healthcare system has a “major problem” vice president of the Advanced Medical 8 Brownlee in her book, . A with “too many patients getting medical Technology Association (“AdvaMed”)— recent poll shows that 67 percent of tests and treatments that they don’t really the trade group that represents medical Americans say the healthcare system has need,” although only 16 percent say they device manufacturers.29 a major problem with “too many patients themselves have received unnecessary

2 Where Does Overuse Occur? BOX 1 Areas of Overuse Overuse occurs in every sector of the health- care industry. See Box 1 for a list of areas in In its 2008 report, National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare, which healthcare suffers from overuse. the National Priorities Partnership identified nine areas in which healthcare suffers from overuse. In 2008, the New England Healthcare They are: Institute (NEHI) compiled 460 studies and • inappropriate medication use (e.g., antibiotics); reports published over 8 years to identify • unnecessary laboratory testing; 30 and place a price tag on 5 areas of waste. • unnecessary maternity care interventions (i.e., inappropriate Cesarean section); NEHI analysts determined that elimination • unwarranted diagnostic imaging; of these areas of waste would result in significant potential cost savings to the • inappropriate nonpalliative services at the end of life (e.g., chemotherapy in the last 14 days of life); healthcare delivery system. They are: • unwarranted procedures; 1. Unexplained variation in the intensity • unnecessary consultations; of medical and surgical services. • preventable emergency department visits and hospitalizations (e.g., hospitalizations lasting less Potential annual savings: $600 billion than 24 hours); and 2. Misuse of drugs and treatments • potentially harmful preventive services with no benefit. resulting in preventable adverse Source: National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. effects of medical care. Potential Washington, DC: National Quality Forum; 2008. annual savings: $52.2 billion 3. Overuse of nonurgent ED care. Potential annual savings: $21.4 billion percutaneous coronary interventions bypass grafting, although the evidence is 4. Underuse of appropriate medications: (PCIs, also known as angioplasties), and actually to the contrary,” says Peter K. — Generic hypertensives: Potential back surgeries. Smith, MD, chief of cardiovascular and annual savings: $3 billion For example, in back surgery, there is thoracic surgery at Duke University 35 — Controller , particularly a 5-fold variation in surgery rates across Health System. inhaled corticosteroids in pediatric the United States, with 71 referral Lack of good care coordination often asthma: Potential annual savings: regions demonstrating rates 30 percent is the root cause of overuse. More services $2.5 billion higher than the national average and 52 do not necessarily lead to better quality hospital referral regions showing rates 25 or increased patient satisfaction; in fact, 5. Overuse of antibiotics for respiratory percent lower than the national average, sometimes precisely the opposite is true. infections. Potential annual savings: according to Dartmouth Atlas researchers. Dartmouth researchers recently examined $1.1 billion Similarly, for CABG surgery, there is a the associations among hospital care Of these factors contributing to 5-fold variation across the nation. For PCIs, intensity, the technical quality of hospital overuse, practice variation accounts for the variation is 10-fold. care, and patients’ ratings of their hospital by far the largest portion of overuse. The This is not to say that there are neces- experiences and found that greater inpa- Dartmouth , in its ground- sarily too many CABGs or angioplasties. tient care intensity (such as more doctor breaking work documenting variation in In fact, in some cases there may be too few. visits and more days in the hospital) was services and costs across the United States, Stents are initially simpler to place, better associated with lower quality scores and provides compelling evidence that supply- tolerated by patients, and less expensive lower patient ratings. The link between induced demand increases the number of than CABG. However, stents are less greater care intensity and lower quality services provided without improving durable than bypass grafting, resulting in and less favorable patient experiences may quality. Regional variations have been more (and more serious) complications be poorly coordinated care, they found.36 31 highlighted recently in the national media over time. These adverse outcomes, Patients are taking notice and voicing their 32 and are feeding the political discourse. along with the need for expensive dual dissatisfaction with this “continuum of The causes of practice variations, antiplatelet therapy, make the ultimate confusion,” in part because comparatively rigorously documented in the Dartmouth expense of “PCI first” greater than a few patients enjoy a continuous healing 33 Atlas, include failure to adhere to estab- “CABG first” strategy, particularly for relationship with a physician. lished clinical practice guidelines, extensive patients with extensive coronary artery “In our current fragmented system of care, and unnecessary care at the end of life, .34 “There is a belief system that every patient is a ‘new patient,’” says overuse of procedures including coronary PCI with stents is superior to medical Bruce Bagley, MD, medical director for artery bypass graft (CABG) surgery, therapy and not inferior to coronary quality improvement for the American

3 Academy of Family Physicians. “Past patients’ and their families’ desires for care BOX 2 Nonurgent ED Visits history, recent testing or previous recom- at the end of life regarding their need for mendations take a backseat to the immedi- comfort. What constitutes a nonurgent ED visit? acy of the moment and the needs to The ED is another setting that is rife 37 Examples include: establish a disposition.” with overuse. This care is extraordinarily • A new mother who cannot get her baby Fragmentation of care can also lead to expensive because of the large number of to stop crying; her doctor’s office is hospitalizations that may be preventable if diagnostic tests associated with most ED closed, and the ED is the best place to there were comprehensive primary care, visits, which results from the lack of infor- get immediate reassurance. good communication across providers and mation about the patient’s condition and • A college student who thinks she has settings, and the availability of necessary the requirement to treat immediately. But strep throat and decides that spending 38 information at the time of admission. not all cases in the ED are emergencies. It a few hours at the ED on a Sunday is better than waiting until the student Among specialists, cardiologists is important to note that the definition of health reopens on Monday. represent the “gold standard” for following “emergency” is in the eye of the beholder. • An elderly home patient who clinical guidelines, but even they do so For example, a young mother of a new- is taken to the ED with dehydration, only 70 percent of the time, according to born may present at the ED with her baby because his facility did not have a Everett’s research. It is necessary to con- who will not stop crying. This may not physician onsite at the time. vince physicians to change behavior, but constitute an emergency in strict medical possible to do so only if presented with the terms, but if that young mother has supporting evidence—and making sure nowhere else to turn and does not know Possible Solutions that physicians are not being blamed as the what to do, she needs that ED visit for singular source of the problem. “When we Overuse is sustained reassurance, and for her the situation is by a culture and social look at overuse from the perspective of a 43 emergent. Nonetheless, in strict financial norms shared among physicians and surgeon, we look at this first as, ‘Someone terms, ED use for medically nonurgent patients that can best be summed up in is trying to judge us for that which I think purposes is costly. According to the Centers the bromide, “better safe than sorry.” I do well,’” says Frank G. Opelka, MD, for Disease Control and Prevention, Physicians are trained to act on behalf of FACS, chair of the American College of 13.9 percent of ED visits in 2005 were for their patients and often recommend treat- Surgeons’ and Quality nonurgent purposes, up from 9.7 percent ments that “might work,” with the implicit Improvement Committee. “Perhaps that’s in 1997. Furthermore, contrary to popular understanding that they might not. They not the right message to send out to our 39 opinion, the majority of these nonurgent are much more concerned about sins of providers.” ED visits were not from patients lacking omission (i.e., failure to treat) than acts of Aggressive healthcare in the last insurance. Although uninsured patients commission. weeks or months of life often constitutes A failure of omission is unpardonable waste. Examples include the provision of account for a disproportionate share of ED to providers, patients, and the legal system. chemotherapy in the last 14 days of life, use, the greatest number of nonurgent ED Patients suffer when sick or injured and which represents an alarming increase in visits came from privately insured individ- understandably demand care to alleviate the aggressive treatment of patients with uals, research shows. “The astonishing fact 40 the pain and anxiety; and physicians are terminal cancers. Unfortunately, this is is that 40 percent are made by privately trained in a culture of doing “everything also an area where there is too little care— insured patients. Two-thirds of patients possible” on behalf of their patients. This . John Mastrojohn, III, RN, have primary care providers,” Everett MSN, MBA, vice president, palliative care, says. See Box 2 for information on what mix of expectations makes the pact of the quality, and research for the National constitutes a nonurgent ED visit. social norm hard to break. A complicating and Palliative Care Organization, Patients resort to ED use for a variety factor is that the concentration on the is fond of quoting the influential author of reasons: lack of regular or preventive patient as an individual and on his or her Eric J. Cassell, MD, when he says, “the fail- care for chronic conditions, the inability to illness takes precedence over implications ure to understand the nature of suffering book a timely primary care appointment, within the broader community. For exam- can result in medical intervention that, referral by their physician, or convenience. ple, in the case of antibiotic overuse, there though technically adequate, not only fails In addition, patients’ perception of their is little concern within the provider-patient to relieve suffering but becomes a source medical problem as a medical emergency, dyad for what might be good for society of suffering itself.”41 Moving patients to which often is contrary to how the condi- (e.g., bacterial resistance, unsustainable hospice earlier reduces costs 70 tion would be clinically classified, is costs), public health, or the patient in the 45 percent of the time, by an average of $2,309 another driver of ED overuse.44 next bed. Hence, the “tragedy of com- per hospice patient,42 and it addresses mons”—the dilemma in which multiple

4 individuals acting independently in their patient engagement through its “Questions better care. Advertising executive Matt own self-interest ultimately destroy a Are the Answer” public information Williams, executive vice president of The shared limited resource even when it is campaign to encourage patients to Martin Agency—who has worked with 51 clear that it is not in anyone’s long-term become more involved in their own care. former Vice President Al Gore on the interest to do so—is particularly worrisome Shannon Brownlee offers examples of Alliance for Climate Protection’s We cam- when it comes to overuse.46,47 questions patients should ask, such as paign, raising national awareness about As with any culture-driven challenge, “How good is the evidence that this global warming—describes a “ladder of solutions exist, but they must be robust, test will reduce my risk of engagement,” starting with consciousness, and they take time to be successful. Some dying?” and “Is the test itself danger- then belief, then behavior change. “Engage 52 of these solutions are “big-ticket” financial ous?” The Center for Advancing Health the passionate minority and set the stakes items, such as payment reform or the produces a series of “Prepared Patient” high,” Williams advises.55 publications that helps people participate implementation of information technology Guidelines and Care Paths systems; other resolutions demand a more fully in their healthcare with topics 53 As noted above, practice variations, change in mindset. None will be easy. It such as “Is this good science?” including failure to adhere to established is not as simple as slicing benefits or A strong movement within health- clinical guidelines, constitute the over- declaring some procedures off-limits to care called “shared decisionmaking” is Medicare beneficiaries. “We need rational encouraging physicians to be receptive to whelming majority of instances of overuse. healthcare, not rationed healthcare,” says those questions. Characteristics of shared Everett suggests that guidelines are not James N. Weinstein, DO, MS, director of decisionmaking include that at least two followed for reasons including: the Dartmouth Institute for parties—the physician and the patient—be • guidelines are not easily accessible; 48 and Clinical Practice. Instead, as patient- involved; that both parties share informa- • guidelines are not updated in a timely and physician-driven medical behavior tion; that both parties take steps to build a fashion; changes, the challenge is to encourage consensus about the preferred treatment; • clinical practitioners trust their own this behavior change in such a way that and that an agreement is reached on the judgment more than established 54 keeps the patient at the center of care and treatment to implement. guidelines; and encourages system improvement and Weinstein, of the Dartmouth Institute • there exists little economic incentive clinical advancement. “Innovation and for Health Policy and Clinical Practice, is a to adhere to guidelines. medical progress does not come automati- longtime practitioner of shared decision- Guidelines work the best when they cally,” says Advamed’s David Nexon. “As making. As a back surgeon, he employs it are from a trusted source, are hard-wired we make changes, we need to be sensitive in his own practice. Weinstein, chair of the into structured decision trees through in a way that supports rather than inhibits Department of Orthopaedic Surgery at health information technology systems, medical innovation.” Dartmouth-Hitchcock Medical Center, and are easily available for clinical deci- Involving Patients in Their Own Care estimates that if patients were fully sionmaking (such as with computerized engaged in the decisionmaking process, The Institute of (IOM) defines physician order entry [CPOE] systems). there would be approximately 30 percent quality care as care that is safe, timely, Similarly, clinical practice pathways reflect fewer back surgeries, given that so many equitable, efficient, efficient, and patient best clinical practices and can be linked to 49 patients find relief from back pain in a centered. Of these aims, patient-centered- quality performance measures, which, ness often is discussed but is difficult to relatively short period without surgery. when publicly reported, can encourage define and measure. IOM has defined “Patients tend to choose the most effective significant behavioral change. patient-centered care as “care that is treatment when they are well informed,” Payment Incentives respectful of and responsive to individual he says. “Shared decisionmaking not only patient preferences, needs, and values results in better outcomes, but in increased Incentives matter to providers and patients. and ensuring that patient values guide all confidence for the patient. Ultimately, Today, the U.S. healthcare system by and clinical decisions.”50 Engaging patients in patients should be empowered to decide large reimburses providers on a per-visit their own care, by treating them as equal what is right for them.” or per-procedure basis. This fee-for-service members of the healthcare team and In addition to shared decisionmaking system provides enormous incentive to encouraging them to speak up rather than at the individual physician-patient level, increase volume, which fuels overuse. be passive recipients of care, is at the core consumers can be engaged at the commu- Therefore, there needs to be a powerful, of patient-centered care. nity level. Physicians and other healthcare countervailing incentive system to reduce There are tools to help patients get leaders can engage in public education unnecessary care and redirect incentives the answers they need. The Agency for campaigns in their communities to convince toward value. Healthcare Research and Quality promotes the public that more care is not necessarily

5 What kind of incentive would it Unfortunately, today’s payment system to caregivers instantaneously along with take to optimize appropriate care? Some not only fails to reward value but in clinical decision support. Information demonstration projects have awarded some instances actually discourages it. technology-enabled systems thereby offer physicians a bonus incentive of up to 2 Gerri Lamb, PhD, associate professor at the possibility of informing the decision- percent of their pay for adhering to clinical Arizona State University and a visiting making process at the point of care, thus guidelines. “This doesn’t hit the radar scholar at Emory University, points to improving the quality of healthcare screen,” Everett says. In surveys conducted conflicts in various payment mechanisms delivered.62 by NEHI, half of physicians are not moved for care as a reason for But, information technology systems by a 2 percent bonus payment; but 87 potentially avoidable hospital admissions are expensive to implement. The American percent of physicians would be somewhat and readmissions of nursing home resi- Recovery and Reinvestment Act of 2009— or much more likely to comply with dents. “Our current reimbursement system commonly known as President Obama’s guidelines if the bonus payment were 9 encourages transfers to rather stimulus bill—contains $19 billion in percent. At a 20 percent incentive, says than looking at improving and helping incentive payments to encourage physi- 63 Everett, “all but the most recalcitrant nursing homes provide care,” she says.61 cians to adopt EHR systems, but this is would think guideline compliance is a Restructuring Medicare reimbursement just a fraction of what it will cost to fully great idea.” Other payment approaches rules to encourage greater care coordina- digitize American healthcare. also address incentives for better efficiency, tion (e.g., incentivizing greater access to NEHI researchers have found that including bundled payments that promote primary care at nursing homes) could approximately 1 in 10 people admitted to adherence to guidelines, as with Geisinger curb overuse. In Box 3, George Halvorson, hospitals suffer a serious, predictable Health System’s ProvenCare package for president and CEO of Kaiser Foundation adverse drug event (ADE) that could be CABG56 and the Prometheus Payment Health Plan and Hospitals, discusses how prevented by CPOE with clinical decision system’s “evidence-informed case rate.”57 the current payment approach can penalize support. ADEs typically lead to an So-called global payments, when combined those who provide the best care. extra 4.6 days in the hospital per patient with risk adjustments and with pay-for- per error. In a study published in Information Technology as a 2008, researchers from NEHI and the performance initiatives, including measures Facilitator of Reform of overuse, are generating significant Massachusetts Technology Collaborative 58 Information technology systems have long determined that in Massachusetts alone, interest. Also, payment for shared deci- been touted as an essential infrastructure CPOE systems could prevent 55,000 med- sionmaking could play an instrumental to influence clinical decisions and to ical errors and save $170 million a year. part in reducing overuse. improve quality. Although not a panacea, Information technology could also Patients, too, respond to incentives. health information technology advances be implemented in other ways to reduce The field of behavioral economics demon- such as CPOE and electronic health record overuse. For example, telemedicine tech- strates that incentives can be structured to (EHR) systems collectively offer the prom- nology could help solve the problem of “nudge” people toward the options that ise of getting complete clinical information limited access to primary care, especially are right for them and society, such as opt-ins for contributions to retirement savings.59 There are applications to health- care. For example, many pharmaceutical BOX 3 The Advantage of Systems Thinking benefit plans offer lower to George Halvorson advocates “systems thinking” as a way to encourage rational care, but points out encourage patients to use generic rather that payment systems currently discourage such thinking. than brand-name medications. Other “nudge” interventions for reducing over- Halvorson offers the example of the Institute for Clinical Systems Improvement in Minnesota, which use can include giving patients a free “cold undertook an initiative to encourage a best practices approach to the treatment of urinary tract infec- tions in women. The initiative improved measurable process improvements by 500 percent within a care kit” for upper respiratory infections year and cut costs by 35 percent, but those costs went directly to providers’ bottom lines. along with a delayed fill prescription to reduce the misuse of antibiotics60 for viral “Rework generated a lot of caregiver revenue. So did unnecessary office visits—visits that could be infections and routinely providing shared eliminated by patient-focused reengineered care delivery,” Halvorson writes. “Providers do not see los- ing 35 percent of their revenue as an economic reward. The current American payment approach decisionmaking services for appropriate directly and immediately penalized the providers who provided best care for those patients.” conditions at no or limited cost to the patient and with reimbursement for the Source: Halvorson GC. Now! A Prescription for Change. San Francisco, CA: Jossey-Bass; 2007. provider.

6 in rural areas, dramatically cutting down medicine and the science of healthcare Acknowledgments on one of the drivers of ED overuse. And, delivery share equal billing with the ulti- Dwight McNeill, Sarah Callahan, and EHRs could much more efficiently glean mate goal being value, defined as quality Ben Yelin, members of NQF staff, and and interpret the data needed to measure divided by cost. Learning organizations, Philip Dunn, Sara Maddox, and Tamara compliance with established clinical guide- Cortese asserts, could ensure transfer of Lee, consultants to NQF, contributed to lines—even enabling a pay-for-compliance information between domains—between G this Issue Brief. incentive program—as well as serve as a knowledge and care delivery and between vehicle to disseminate new or updated care delivery and payer—so that better Notes guidelines and quickly integrate them into practices are communicated quickly and clinical decision support tools. efficiently, ensuring that evidence-based 1 An J, Saloner R, Ranji U, U.S. Health Care Costs: Background Brief, Washington, DC: Kaiser Family care is always delivered to patients and Foundation; 2008. Available at www.kaiseredu.org/ Conclusion thus curbing overuse. topics_im.asp?imID=1&parentID=61&id=358. Payment reform is a component of a Last accessed April 2009. Health reform presents 2 Frontsin P, Sources of Health Insurance and both a challenge and health system transformation that reduces Characteristics of the Uninsured: Analysis of the an opportunity: to transform American overuse. So is information technology. March 2008 Current Population Survey, Washington, healthcare. Doing so requires more than But each, as a stand-alone solution, is DC: Employee Benefit Research Institute (EBRI); simply modifying parts of the current Issue Brief No. 321; 2008. Available at incomplete. What is required is a culture www.ebri.org/pdf/briefspdf/EBRI_IB_09a-2008.pdf. healthcare system; it requires rational change that incorporates payment reform Last accessed April 2009. thinking about how all elements of the and information technology, questions 3 Office of Management and Budget, A New Era of Responsibility: Renewing America’s Promise, healthcare enterprise interact with each entrenched and implied social contractual Washington, DC: GPO; 2009. Available at other, says Denis A. Cortese, MD, president obligations between patient and providers, www.gpoaccess.gov/usbudget/fy10/pdf/fy10- 64 and CEO of the . and puts the patient at the center of every newera.pdf. Last accessed May 2009. Cortese observes a healthcare delivery healthcare transaction. “We need to appre- 4 Wennberg J, Brownlee S, Fisher E, et al., An Agenda for Change: Improving Quality and Curbing Health system composed of three domains: ciate even more the question of, ‘what do Care Spending: Opportunities for the Congress and knowledge (e.g., medical research), care my patients want?’” says Dartmouth’s the Obama Administration, A Dartmouth Atlas White Paper, Lebanon, NH: The Dartmouth Institute for delivery (e.g., hospitals, physicians), and Weinstein. “Only providing what is Health Policy & Clinical Practice; 2008. Available at payers (e.g., health plans, Medicare). necessary and according to your patients’ www.dartmouthatlas.org/topics/agenda_for_ “Each of these domains works well within preferences doesn’t suppress your practice. change.pdf. Last accessed April 2009. its own construct, as it is designed to do,” It gets you to the right practice.” 5 National Priorities Partnership, National Priorities and Goals: Aligning Our Efforts to Transform he says. “The problem is at the interface Curbing overuse should not be America’s Healthcare, Washington, DC: National between domains.” For example, IOM synonymous with cutting access. In fact, Quality Forum (NQF); 2008. Available at notes that it takes 17 years on the average if implemented correctly in an organized, www.nationalprioritiespartnership.org/assets/0/72/ 14362e4d-e9e2-45fe-8484-d5d97048968c.pdf. Last to implement a clinical recommendation learning system of care, reducing overuse accessed May 2009. 65 into everyday practice —that is, to ideally should increase access. A health- 6 Ibid. transfer information from the knowledge care system that is evidence based, that is 7 Corrigan JM, Speech at NQF Spring Implementation Conference, Cleveland, Ohio, March 25-27, 2009. domain to the care delivery domain. accountable, and that uses information Instead of a system, Cortese says, the 8 Brownlee S, Overtreated: Why Too Much Medicine technology wisely and focuses on value Is Making Us Sicker and Poorer, New York: United States has a collection of interde- will reduce the “epidemic of care” and cre- Bloomsbury USA; 2007. pendent entities that each protects its own ate a safer and better healthcare system66 9 National Public Radio/Henry J. Kaiser Family Foundation/Harvard School of Public Health self-interests, with little thought put into that places a high premium on value, (NPR/KFF/HSPH), The Public and the Health Care how they behave as a whole. “There’s innovation, and patient-centeredness. Delivery System. Poll conducted March 12-22, 2009. nothing really broken about our system Today, however, the evidence is clear Available at www.kff.org/kaiserpolls/upload/ 7887.pdf. Last accessed April 2009. because there isn’t one. Nobody designed that resources are being wasted in a way 10 Henry J. Kaiser Family Foundation, Kaiser Health it, so you can’t fix it—because it doesn’t that is not only expensive but also denies Tracking Poll—February 2009. “More than half of exist.” But Cortese envisions something care to those who need it. Rationalizing Americans say family skimped on medical care because of cost in past year; worries about afford- entirely different: an organized delivery healthcare does not mean rationing it; it ability and availability of care rise.” Available at system composed of “learning organiza- means reducing overuse so that resources www.kff.org/kaiserpolls/posr022509pkg.cfm. Last tions,” in which integration and coordina- can be redirected, with the goal of getting accessed May 2009. tion of care exist as the foundation. In the right care to every patient, every time. Cortese’s systemic vision, individualized

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8 57 de Brantes F, Camillus JA, Evidence-Informed Case Rates: A New Health Care Payment Model, New York: Commonwealth Fund; Pub. No. 1022; April 2007. Available at www.commonwealthfund.org/~/ media/Files/Publications/Fund%20Report/2007/Apr/ Evidence%20Informed%20Case%20Rates%20%20A %20New%20Health%20Care%20Payment%20Model/ deBrantes_evidence%20informedcaserates_1022 %20pdf.pdf. Last accessed June 2009. 58 Kowalczyk L, State seeks to revamp way doctors, hospitals are paid, Boston Globe, May 7, 2009. Available at www.boston.com/news/local/ NATIONALNQFQUALITY FORUM massachusetts/articles/2009/05/07/state_seeks_to_ revamp_way_doctors_hospitals_are_paid/. Last accessed May 2009. 59 Thaler RH, Sunstein CR, Nudge: Improving Decisions NQF’s mission is to improve the About Health, Wealth, and Happiness, New Haven, CT: Yale University Press; 2008. quality of American healthcare 60 The McDonnell Norms Group, Antibiotic overuse: the by setting national priorities influence of social norms, J Am Coll Surg, 2008;207 and goals for performance (2):265-275. improvement, endorsing 61 Lamb G, Speech at NQF Spring Implementation national consensus standards Conference, Cleveland, Ohio, March 25-27, 2009. for measuring and publicly 62 NQF, “Wired for Quality: The Intersection of Health reporting on performance, and IT and Healthcare Quality,” Issue Brief, no. 8 promoting the attainment of (March 2008), Washington, DC: NQF. Available at www.qualityforum.org/news/Issuebriefsandnews national goals through educa- letters/ibhitMar08.pdf. Last accessed April 2009. tion and outreach programs. 63 U.S. Congress, The American Recovery and Reinvestment Act of 2009, Washington, DC: GPO. NQF Issue Briefs provide Available at http://frwebgate.access.gpo.gov/ insight into payer, policy, and cgi-bin/getdoc.cgi?dbname=111_cong_bills& industry efforts to promote docid=f:h1enr.pdf. Last accessed April 2009. quality healthcare. Sustaining 64 Cortese D, Speech at NQF Spring Implementation Conference, Cleveland, Ohio, March 25-27, 2009. support is provided by the Available at www.qualityforum.org/conference/ Cardinal Health Foundation. presentations/Slides%203.25.09/Denis%20Cortese %203.25.09.pdf. 65 IOM, Crossing the Quality Chasm: A New Health System for the 21st Century, Washington, DC: National Academy Press; 2001. 66 Halvorson GC, Isham GJ, Epidemic of Care: A Call for Safer, Better and More Accountable Health Care, San Francisco, CA: Jossey-Bass; 2003.

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Issue Brief No. 15 June 2009

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